Visualize HL7 Example and Test Instances (vi7eti)

Visualize HL7 Example and Test Instances (vi7eti), pronounced /viːˈsɛtiː/

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Patient
Name:	Ferreira, Vicente
DOB:	26-DEC-1941 (Age: 83)
Gender:	male
Address:	R São Domingos 111 2645-065 Alcabideche (Portugal)
ID:	7321-512116-8

Report
Date:	24-JUN-2025

Laboratory

Requested by
CASP -Centro de Apoio Social do Pisão 2710-631 Sintra (Portugal)

Specimen
Collected:	23-JUN-2025

This seems not to be an HL7 Europe Laboratory Report (type coding LOINC 11502-2)

Chemistry

Test	23 Jun 2025	Reference Range	Unit
Glucose [Mass/volume] in Serum or Plasma	93.3	70 - 99	mg/dL
Urea nitrogen [Mass/volume] in Serum or Plasma	8.3	7 - 20	mg/dL
Creatinine [Mass/volume] in Serum or Plasma	2.0 H	0.9 - 1.3	mg/dL
Calcium [Mass/volume] in Serum or Plasma	8.6	8.5 - 10.5	mg/dL
Sodium [Moles/volume] in Serum or Plasma	143.6	135 - 145	mmol/L
Potassium [Moles/volume] in Serum or Plasma	5.2 H	3.5 - 5	mmol/L
Chloride [Moles/volume] in Serum or Plasma	101.9	98 - 108	mmol/L
Carbon dioxide, total [Moles/volume] in Serum or Plasma	22.0	22 - 29	mmol/L
Ketones [Presence] in Urine by Test strip	Urine ketone test = ++
Hemoglobin A1c/Hemoglobin.total in Blood	3.6 L	4 - 6	%

Urinalysis

Test	23 Jun 2025	Reference Range	Unit
Glucose [Mass/volume] in Urine by Test strip	2.1 H	0 - 0.1	mg/dL
Glucose [Presence] in Urine by Test strip	++
Bilirubin.total [Mass/volume] in Urine by Test strip	1.4	0 - 1.7	mg/dL
Bilirubin.total [Presence] in Urine by Test strip	Finding of bilirubin in urine
Ketones [Mass/volume] in Urine by Test strip	11.5 H	0 - 0.6	mg/dL
Specific gravity of Urine by Test strip	1.0 L	1.01 - 1.03	{nominal}
pH of Urine by Test strip	5.3	4.5 - 7	pH
Protein [Mass/volume] in Urine by Test strip	279.2 H	0 - 14	mg/dL
Protein [Presence] in Urine by Test strip	Urine protein test = ++
Nitrite [Presence] in Urine by Test strip	Urine nitrite negative
Hemoglobin [Presence] in Urine by Test strip	Urine blood test = negative
Leukocyte esterase [Presence] in Urine by Test strip	Urine leukocyte test negative

Annotation

Conclusion and Recommendations based on this report and previous findings known to us
The patient shows persistently elevated creatinine, proteinuria, glycosuria, and ketonuria, suggesting significant renal impairment with possible tubular dysfunction. Urine is consistently abnormal in appearance and color, with low specific gravity, indicating impaired concentrating ability. Blood glucose is normal, but HbA1c is low, making diabetes unlikely. Mild hyperkalemia is present. No evidence of urinary tract infection. Recommend nephrology evaluation for chronic kidney disease and further assessment of possible underlying causes (e.g., tubulointerstitial disease, nephrotic syndrome).

Conclusion and Recommendations based on this report and previous findings known to us

The patient shows persistently elevated creatinine, proteinuria, glycosuria, and ketonuria, suggesting significant renal impairment with possible tubular dysfunction. Urine is consistently abnormal in appearance and color, with low specific gravity, indicating impaired concentrating ability. Blood glucose is normal, but HbA1c is low, making diabetes unlikely. Mild hyperkalemia is present. No evidence of urinary tract infection. Recommend nephrology evaluation for chronic kidney disease and further assessment of possible underlying causes (e.g., tubulointerstitial disease, nephrotic syndrome).